Neurology Asia

The characteristics of atherosclerotic plaque associated with onset of acute ischemic stroke: a high-resolution magnetic resonance imaging study

Dongsen Zhang — 2025-04-01

Background & Objective: The onset of cerebrovascular events is closely related to status of atherosclerotic plaque, especially vulnerable plaques, but the majority of vulnerable plaques remain clinically silent. This study aimed to investigate the characteristics of high-risk vulnerable plaque that correlate with the onset of acute ischemic stroke.

Methods: In this retrospective study. Patients were recruited if they conformed to acute unilateral internal carotid artery or middle cerebral artery territory infarction identified as artery to artery embolization with conjugated vulnerable plaque of bilateral internal carotid artery siphon or middle cerebral artery M1segment vulnerable plaques by 3.0-T high-resolution magnetic resonance imaging examination. Characteristics of vulnerable plaques were compared between culprit plaque and non-culprit plaque of the same patient.

Results: A total of 78 patients (64 males; mean age = 58.49 ± 10.38 years) were included. There were statistically significant difference in irregular surface, degree of stenosis, eccentricity index between culprit plaque and non-culprit plaque (P <0.05). Multivariate analysis showed that irregular surface (OR 5.897, 95%CI, 2.355-14.767, P <0.001), moderate stenosis (OR 3.163, 95%CI, 1.208 -8.283, P =0.019), and plaque enhancement (OR 2.551, 95%CI, 1.028 -6.328, P =0.043) were associated with culprit plaque. The area under the curve of plaque enhancement of irregular surface combined with moderate stenosis was 0.816 (95% CI 0.748-0.884, p =0.000). Plaque enhancement of irregular surface combined with moderate stenosis was associated with END (OR 2.131, 95% CI 1.224-3.712, p=0.008).

Conclusions: Plaque enhancement of irregular surface combined with moderate stenosis may be potential imaging markers for predicting the occurrence of thromboembolic strokes caused by intracranial large artery atherosclerosis and early neurologic deterioration.

Evaluation of malnutrition and cognitive performance in patients with acute stroke

Fatmanur Hümeyra ZENGİN — 2025-04-01

Objective: To evaluate nutritional risk using Global Leadership in Malnutrition (GLIM) criteria and Mini Nutritional Assessment Test (MNA) score, cognitive performance using Montreal Cognitive Assessment (MoCA) and Mini Mental State Examination (MMSE) scores, and the association of nutritional risk with cognitive status.

Methods: The study sample consists of 135 acute stroke patients hospitalized in a neurology clinic in Turkey. A questionnaire was used to determine the sociodemographic characteristics of the patients. MNA and GLIM criteria were used to evaluate nutritional status, the Modified Rankin Scale was used to determine the severity of stroke, and MMSE and MoCA tests were used to determine cognitive performance using a face-to-face interview technique. Anthropometric measurements of the patients were also taken.

Results: Univariate ANOVA analysis found significant association of stroke severity and malnutrition status on cognitive performance scores separately (p<0.005). However, no significant association was observed with multivariate analysis. When various risk factors association were examined against dementia according to MMSE and MoCA, with univariate logistic regression analysis, gender, age, and education status was associatred with dementia. The risk of dementia increased 6.6 times in women and 1.1 times as age increased according to the MMSE score. The risk of dementia increased 4.2 times in women and 1.1 times as age increased according to the MoCA score. However, with multivariate analyses, it was found that only age had significant effect.

Conclusion: Evaluation of cognitive function and nutritional status is essential for stroke patients. Evaluation of stroke patients with a multidisciplinary approach can contribute to the prognosis of the disease.

The effect of aortic arch calcification on in-hospital mortality in patients with hemorrhagic stroke

SEFA TATAR — 2025-04-01

Background & Objective: The association between calcifications in the aortic arch and cardiovascular, particularly cerebrovascular, diseases has been widely discussed in the literature. This study aims to investigate the impact of the severity of aortic arch calcification on mortality and morbidity in patients who have experienced a hemorrhagic stroke.

Methods: The study included 187 patients with hemorrhagic stroke. Clinical, demographic, echocardiographic, and laboratory characteristics of patients who presented to the hospital within the first 24 hours were obtained from hospital discharge summaries and records. The study examined whether there was a difference in the severity of aortic arch calcification between survivors and the in-hospital mortality group. Additionally, the relationship between the severity of aortic arch calcification and morbidity, hemorrhage volume, and localization was investigated.

Results: Systolic and diastolic blood pressures were found to be lower in the mortality group (p < 0.05). In the mortality group, total cholesterol, ejection fraction (EF), and platelet count (PLT) were significantly lower, while glucose, creatinine, NIHSS score, and modified Rankin score were significantly higher (p<0.05). Other epidemiological factors and risk factors did not differ from the surviving group (p>0.05). Aortic arch calcification was found to have no significant impact on mortality, morbidity, hemorrhage volume, or hemorrhage localization (p>0.05).

Conclusion: Vascular calcification is an important risk factor for stroke. Calcifications in large vessels like the aorta are expected to also develop in relatively smaller cerebral vessels. While increased vascular calcification heightens the risk of hemorrhagic stroke, higher severity of aortic arch calcification does not contribute additional risk for mortality in cases of hemorrhagic stroke.

Efficacy and safety of endovascular thrombectomy in acute ischemic stroke with large ischemic cores: A meta-analysis of randomized controlled trials and cohort studies

Wu Bing — 2025-04-01

Background: The efficacy and safety of endovascular thrombectomy (EVT) in patients with large ischemic infarcts have been the focus of recent research, yet discrepancies persist between studies. This meta-analysis evaluates the efficacy and safety of EVT using data from randomized controlled trials (RCTs) and real-world cohort studies.

Methods: A systematic search of PubMed, Web of Science, and Embase from January 1, 2010, to June 17, 2024, identified studies reporting favorable functional outcome (FFO), moderate functional outcome (MFO), symptomatic intracranial hemorrhage (sICH), mortality, early neurologic improvement (ENI), and other outcomes.

Results: Six RCTs and 21 cohort studies with 5,919 patients were analyzed. EVT significantly improved FFO (RR 2.49, 95% CI 1.89–3.29), MFO (RR 1.92, 95% CI 1.50–2.44), ENI (RR 2.34, 95% CI 1.77–3.09), and mRS shift (Generalized OR 1.45, 95% CI 1.32–1.61; Common OR 2.03, 95% CI 1.49–2.75) at 90 days compared to best medical treatment. EVT did not significantly increase sICH risk (RR 1.68, 95% CI 0.99–2.84; RR 1.61, 95% CI 0.80–3.23) or mortality (RR 0.86, 95% CI 0.72–1.02) but was associated with a higher incidence of any intracranial hemorrhage (ICH) (RR 1.74, 95% CI 1.28–2.36). Rates of early neurological worsening and decompressive craniectomy were similar between groups. Findings from RCTs and real-world cohort studies were consistent, reinforcing the robustness of the results.

Conclusion: EVT improves functional outcomes in patients with large ischemic cores without increasing the risk of sICH or mortality, though it is associated with a higher incidence of ICH. Further studies are necessary to refine patient selection and confirm long-term benefits.

Endovascular treatment in the posterior circulation stroke: A retrospective study

Fatih Hakan Tufanoğlu — 2025-04-01

Background & Objective: Posterior circulation stroke accounts for approximately 20% of all ischemic strokes and is a serious neurological event affecting a different areas of the brain. Although endovascular treatment is the gold standard for stroke in the anterior circulation system, there is no consensus on the best treatment in the posterior circulation system. We aimed to demonstrate the effectiveness and safety of the procedure in posterior circulation system stroke.

Methods: Patients older than 18 years of age who had been diagnosed with a stroke in the posterior circulation system are included. Symptom duration, Alberta Stroke Program Early Computed Tomography scores in the posterior system, occlusion level, arrival Glascow Coma Scores (GCS), admission National Institute of Health Stroke Scale scores, 90-day mortality, modified treatment score for cerebral infarction and 3rd month modified Rankin Scores (mRS) were examined retrospectively.

Results: The study population included 29 patients. Average procedure duration and average symptom duration was calculated as 61.72±49.09 and 235.90±153.13 minutes respectively. Average GCS score was found to be 8.86±4.27. Most of the occlusions were distal basilar (51.7%). Revascularization was achieved in 82.8% (n=24) of the cases. Favourable outcome (mRS ≤3 ) was achieved in 41.3% of the cases. Three cases of symptomatic haemorrhage occured after the treatment.

Conclusion: Although the success of the procedure in the posterior circulation system is relatively high, the desired good functional outcome rates still remain low. Ensuring rapid diagnosis of patients and shortening the duration of symptoms will positively affect the prognosis.

Effect of boxing therapy on upper-limb function, balance, and quality of life in stroke patients: A randomized controlled trial

Mubara Afzal — 2025-04-01

Background: Active engagement of stroke patients in rehabilitation is directly linked with better functional performance. Boxing therapy is one of the innovative approaches that have been used to improve the active patient participation. Objective: To determine the additional effects of boxing therapy along with task-oriented training on upper limb function, balance, and quality of life in stroke patients.

Methods: This randomized control trial was conducted on thirty stroke patients - of either gender, age (40 to 60 year) and able to sit for at least 2 minutes - recruited through non-probability convenience sampling and randomly assigned into two equal groups: Boxing Therapy (BT) and Task-Oriented (TO) through sealed envelope method. Both groups received task-oriented training while BT group received additional concurrent boxing therapy for 8 weeks, 3 times per week. Fugl-Meyer-Upper Extremity, Wolf Motor Function Test, Berg Balance Scale, and Stroke Specific Quality of Life Questionnaire were used for assessment at baseline and after 4 and 8 weeks of intervention. Data was analyzed using SPSS.

Results: The between-group analysis showed the statistically significant difference in both group in terms of Fugl-meyer assessment for upper extremity, Wolf motor function test, Berg balance scale, and Stroke specific quality of life questionnaire (p<0.05). Within group analysis of all the variables are statistically significant for both groups (p<0.05).

Conclusion: The study found that boxing therapy has additional beneficial effects on upper limb function, balance and quality of life as compared to only task-oriented training in stroke patients.

Home-based neuromuscular electrical stimulation (NMES) program for chronic post-stroke lower limb spasticity: A single-arm pilot study

Raja Nabila Raja Mohamed Anuar — 2025-04-01

Background & Objectives: Post-stroke spasticity often leads to gait abnormalities, posing challenges for patients. Non-invasive neuromuscular electrical stimulation (NMES) offers a promising avenue for treatment. Despite the availability of portable NMES devices, there is a gap in understanding patient perceptions and outcomes of home-based NMES programs targeting lower limb spasticity post-stroke. This single-arm pilot study aimed to assess the impact of a home-based NMES program on spastic ankle plantar flexors and the feasibility of the program. Primary objectives focused on spasticity levels, ankle range of motion (ROM), dorsiflexor strength, walking speed, and lower-extremity function, while secondary objectives included retention rates, adherence rates, and patient feedback.

Methods: Participants with plantar flexor spasticity rated Modified Ashworth Scale (MAS) 1+ to 3 received 20-minute NMES sessions daily, 5 days/week, for 4 weeks alongside conventional rehabilitation. Primary objectives were assessed using the MAS, Medical Research Council (MRC) scale, 10 meter walk test (10MWT), and Fugl-Meyer Assessment of Lower Extremities (FMA-LE), while secondary objectives were evaluated using structured questionnaires.

Results: Ten participants were recruited, and nine completed the study with high adherence rates. All completers adhered to 20 sessions, except for one patient who completed 80% of the sessions. Positive feedback was received, and no adverse effects were reported. Significant improvements were noted in ankle ROM (5.56 degrees ± 3.38, p-value = 0.002) and spasticity (MAS reduction of 0.55 ± 0.93, p-value = 0.013). However, other functional outcomes did not show any significant improvement.

Conclusion: The home-based NMES program proved feasible and was well received by chronic stroke patients, demonstrating notable enhancements in ankle range of motion (ROM) and, to some extent, improvements in spasticity levels. Larger randomized controlled trials are warranted to further validate its potential benefits and effectiveness.

Translation and validation of the Turkish version of the Subjective Index of Physical and Social Outcome (SIPSO)

Dilek Baykal — 2025-04-01

Background & Objectives: Stroke is a disease that causes disability and death all over the world. Evaluation of physical and social outcomes after stroke is important in improving quality of life and well-being. The objective of this study is translating the Subjective Index of Physical and Social Outcome (SIPSO) into Turkish and examining its validity and reliability.

Methods: This study used translation and back translation for the scale’s language equivalence and expert opinion for the content validity. An expert panel and 8 individuals with SIPSO evaluated the scale for validity. The scale’s reliability was assessed by internal consistency. Pearson correlation, and test-retest reliability were performed in 111 stroke patients. The scale’s construct validity was tested with confirmatory factor analysis and exploratory factor analysis.

Results: The Cronbach’s alpha value was 0.972, and the scale was found to have a high degree of internal consistency. In confirmatory factor analysis, it was confirmed that the scale two factors: “physical and social outcomes”. In the factor analysis, two factors emerged from the scale, and after the confirmatory factor analysis and scale modification, the fit indices of the model were found to provide a good level of validity. The scale is capable of distinguishing between introductory features and the physical and social consequences of stroke.

Conclusion: SIPSO Turkish version is a valid and reliable scale that can be used in studies evaluating the physical and social effects of stroke.

Factors affecting caregiver burden in older stroke survivors, a Malaysian study

Nor Hazwani Zenol Ariffin — 2025-04-01

Background: Older stroke survivors may suffer from a wide range of disabilities. Delivering care in community impose different sets of challenges. Caregiving role may affect caregiver’s physical and mental health. This study aimed to determine the caregiver burden of stroke survivors in urban Malaysia, an emerging economy.

Methods: Caregivers of stroke patients aged 60 years and above were recruited. Socio-demographic information, stroke care details, Modified Ranking Scale and Barthel Index data were collected followed by Short Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Modified Caregiver Strain Index and Zarit Burden Interview questionnaires.

Results: A total of 104 stroke caregiver-survivor pairs were recruited. The mean age of the caregiver was 50.2 (SD=14.3) years with 72.1% were children of stroke survivors. The mean age of the stroke patients was 72.9 (SD=7.7) . 53.8% of caregivers experienced burden, however majority reported mild to moderate burden. The predictors of overall burden include caregiver’s higher education level (P=0.027, R2=0.506), caregiver having hypertension (P=0.02, R2=0.506), patient having hypertension (P<0.001, R2=0.506) and patient’s worse cognitive decline (P<0.001, R2=0.506). Other important factors include incontinence, higher dependency status and longer duration of care per day.

Conclusion: This study performed in Malaysia described the stroke care burden as mild to moderate, probably reflecting the underlying Eastern culture value with emphasis on family and filial piety.

Additional value of intracranial vessel wall MRI as an adjunct to MRA in further differentiation of Moyamoya vasculopathy in Malaysia

Kartini Rahmat — 2025-04-01

Background & Objective: Moyamoya vasculopathy (MMV) is characterised by the progressive occlusion of the distal internal cerebral arteries (ICA) and its terminal branches, classified into Moyamoya disease (MMD) and Moyamoya syndrome (MMS). Differentiating between MMD and MMS is crucial for appropriate treatment planning. While luminal imaging aids in diagnosis, distinguishing features can sometimes be subtle. This study evaluates the additional diagnostic value of vessel wall magnetic resonance imaging (MRI) in differentiating MMD from MMS.

Methods: Patients with clinical and imaging suspicious features of MMV underwent MRI, including additional vessel wall imaging (VWI). Two neuroradiologists initially reviewed the luminal imaging for features of MMV, and a presumed diagnosis was made in consensus. These luminal images were then correlated with clinical data to classify cases as MMD or MMS, serving as the gold standard diagnosis in this study. Subsequently, the VWI and luminal images were reviewed together, blinded to the initial luminal diagnoses and clinical data, to assess diagnostic accuracy by comparing both methods. The imaging parameters analysed included vessel wall thickening, grading, pattern of wall enhancement, and degree of collateral vessel formation.

Results: Eighteen patients were analysed, comprising 12 with MMD and 6 with MMS. 108 vessels were evaluated, showing improved diagnostic accuracy from 55.6% to 77.8% when combining luminal and VWI. Specificity increased from 16% to 83%, with the positive predictive value rising to 90% and the negative predictive value to 62%. Our study found that MMD and MMS predominantly manifested concentric wall thickening, with no significant difference between the two groups. However, a significant difference was observed in the grading of wall enhancement, as most of the lesions in MMD showed no enhancement, whereas MMS lesions mostly exhibited moderate enhancement.

Conclusion: VWI demonstrates promise as a valuable modality for distinguishing between MMD and MMS when integrated with conventional imaging techniques.

Prevalence and factors associated with adverse therapeutic outcomes of antiseizure medication therapy in people with epilepsy

ROSE ANIZA RUSLI — 2025-04-01

Background: Antiseizure medication (ASM) therapy has been the mainstay of the pharmacological management of epilepsy. The goal of treatment includes achieving good seizure outcomes while minimising the risk of adverse effects (AE). In developing countries, the therapeutic outcomes remain suboptimal. This study aimed to determine the prevalence of ASM therapeutic outcomes and its associated factors.

Methods: This study was conducted in a public, hospital-based specialist clinic. People with epilepsy (PWE) who were prescribed at least one ASM were screened for eligibility. The therapeutic outcomes were assessed using established tools: the Seizure Severity Questionnaire (SSQ) and Liverpool Adverse Events Profile (LAEP), respectively. The patient’s information and responses were recorded, and all relevant data was collected.

Results: Three hundred and ninety-seven PWE were included in the analysis, of which 105 were included in the face-to-face outcome assessment. It was found that 79.3% of the PWE had poor seizure control. The mean SSQ score was 1.44 (±SD:1.34), and the mean LAEP score was 24.0 (±SD:5.91). Epilepsy duration of >10 years (OR: 1.87, 95%CI:1.10- 3.17), generalised onset (OR:7.42, 95%CI:2.95-18.66), focal onset (OR:8.24, 95%CI:2.98- 22.77), non-adherence (OR:3.55, 95%CI:1.52, 8.27) and having ≥3 ASM (OR:3.29 (95%CI:1.32-8.24) were factors associated with poor seizure control. For seizure severity, younger age at onset (OR:3.29, 95%CI:1.32-8.24) and neurological deficit (OR:3.55, 95%CI:1.52-8.27) increased the tendency to have more severe seizures. The factors associated with AE occurrence were advancing age (OR:0.12, 95%CI:0.03-0.20), shorter epilepsy duration (OR:2.89, 95%CI:0.50-5.29), and PWE who had changes in their ASM regimen within the past year (OR:2.93, 95%CI:0.24-5.62).

Conclusion: Factors related to individuals’ demographic and clinical characteristics are associated with adverse outcomes of ASM therapy. Recognising PWE at risk of adverse outcomes is crucial for improving overall epilepsy management.

The effect of mindfulness-based approaches on epilepsy patients: A systematic review

Semra Usta — 2025-04-01

Objective: This study was conducted to systematically examine the effects of mindfulness-based approaches on patients with epilepsy.

Methods: PRISMA criteria were taken as the basis for creating the systematic review protocol and writing the article. In this systematic review, the literature search was performed by searching randomized controlled trials and quasi-experimental studies from Pubmed, Scopus, Cochrane, and Web Of Science databases between 2019 and 2024. The systematic review followed PRISMA guidelines. Inclusion and exclusion criteria were determined using the PICOS method, and 5 studies were included. These studies included in the review were evaluated according to the Joanna Briggs Institute (JBI) critical appraisal lists according to their types.

Results: Five studies, including 3 randomized controlled studies and 2 quasi-experimental studies, were included in our systematic review study. In the studies included in the research, a mindfulness-based approach was applied to epilepsy patients. In all studies included in the scope of the research, it was concluded that a mindfulness-based approach reduced anxiety symptoms in epilepsy patients, improved cognitive balance of emotions and ability to react, increased sexual function, and reduced gender-related distress. The mindfulness-based approach improved the quality of life and reduced symptoms of depression in both group and individual adults with epilepsy.

Conclusion: In line with these results, a mindfulness-based approach is beneficial to alleviate symptoms and develop coping mechanisms in epilepsy patients. In this direction, it is thought that more studies with high levels of evidence evaluating the effectiveness of a mindfulness-based approach are needed. In addition, awareness-based approach training protocols can be developed for mental health professionals, and in-service training can be provided and applied on different patient groups to contribute to the field.

Evolving etiology and resistance patterns in bacterial meningitis: A comparative study over two decades

Fatima Khan — 2025-04-01

This study examines the evolution of bacterial meningitis etiology and antimicrobial resistance patterns over 20 years at a tertiary care centre in Aligarh, India. Comparing two periods (2001-2009 and 2015-2021), we identified a shift from gram-positive to gram-negative bacteria as the primary pathogens, with Staphylococcus aureus decreasing from 37.7% to 26.6% and Klebsiella pneumoniae increasing from 4.7% to 14.4%. Resistance trends show a significant decline in the effectiveness of antibiotics, particularly macrolides, fluoroquinolones, and cephalosporins. Aminoglycosides retained moderate efficacy, while carbapenem resistance increased from 0% to 56.3%, and Extended-Spectrum Beta-Lactamase (ESBL) production rose from 10% to 22.2%. The study highlights an urgent need for updated treatment protocols and enhanced surveillance to address the rising resistance and evolving pathogen landscape in bacterial meningitis.

High-resolution ultrasound findings of the median nerve in electrophysiologically severe carpal tunnel syndrome

Madhu Nagappa — 2025-04-01

Objective: Carpal tunnel syndrome (CTS) is caused by entrapment of the median nerve at the wrist. Nerve conduction studies (NCS) confirm the diagnosis and grade the severity. High-resolution ultrasound (HRUS) is useful for diagnosing CTS and excluding alternative etiologies. However, data on sonological characteristics of electrophysiologically severe CTS are limited. We aim to describe the sonological characteristics of patients with severe CTS.

Methods: Fifty-two adults fulfilling the American Association of Neuromuscular and Electrodiagnostic Medicine practice parameters for the diagnosis of CTS and absent median nerve sensory action potential (severe CTS) were included. Cross-sectional areas (CSA) of the median nerve were obtained at the level of the carpal tunnel inlet and mid-forearm. The wrist-to-forearm ratio (WFR) was calculated. These findings were compared with 60 age- and gender-matched healthy controls.

Results: In the patient group, the mean median nerve CSAs (in mm2) at the wrist and forearm and WFR were 15.64±3.7, 5.53±0.7 and 2.86±0.7 respectively, while in the control group, these were 7.50±0.9, 4.91±0.7 and 1.56±0.3 respectively. All parameters were significantly higher in patients compared to controls. A threshold value of 10.45 mm2 for median nerve CSA at the wrist showed a high accuracy for severe CTS. A threshold value of WFR of 2.07 showed high sensitivity and specificity of 94.2% and 98.3%, respectively.

Conclusion: The present study provides robust data on the sonological characteristics of severe CTS. HRUS being a non-invasive tool, can be used to identify severe CTS at the point of care.

Efficacy of azathioprine and mycophenolate mofetil in acetylcholine receptor antibody positive generalized myasthenia gravis patients

NARUPAT SUANPRASERT — 2025-04-01

Background & Objective: Corticosteroids are the first-line immunosuppressive drug. Azathioprine and mycophenolate mofetil are commonly used as steroid-sparing agents or additional immunosuppressive drugs. However, the efficacies of azathioprine and mycophenolate mofetil are lacking, especially in acetylcholine receptor antibody-positive generalized myasthenia gravis patients (AChR Ab-positive generalized MG). The objectives are firstly to determine the efficacy of azathioprine in AChR Ab- positive generalized MG patients; and secondly to determine the efficacy of mycophenolate mofetil in patients who did not respond or were intolerant to azathioprine.

Methods: A retrospective study of AChR Ab-positive generalized MG patients who were treated with prednisolone in combination with azathioprine and who had switched treatment from azathioprine to mycophenolate mofetil was conducted. Treatment response and adverse effects were evaluated.

Results: Of 105 patients, 95 patients (90.5%) could tolerate and respond to prednisolone in combination with azathioprine, 6 patients (5.7%) had adverse effects, and 4 patients (3.8%) did not respond to azathioprine. Patients who had adverse effects or did not respond to azathioprine were switched to mycophenolate mofetil. Of the 105 patients, 7.6% had MGFA Post-intervention Status (MGFA-PIS) at the last follow-up or before switching from azathioprine to mycophenolate mofetil as Complete Stable Remission (CSR), 2.9% as Pharmacologic Remission (PR), 10.5% as Minimal Manifestations -1 (MM-1), 30.4% as MM-2, 48.6% as MM-3 and the median Medical Research Council (MRC) sum score was 60.0 points. Ten of the 105 patients were switched from azathioprine to mycophenolate mofetil. MGFA-PIS was better after switching treatments in these ten patients than that before the switching.

Conclusion: This study supports the efficacy and safety of azathioprine as an additional immunosuppressive drug in combination with prednisolone for treatment in AChR Ab-positive generalized MG patients. Mycophenolate mofetil can be considered as alternative immunosuppressive drug for patients who cannot tolerate adverse effects or have no response to azathioprine.

Literacy at the synapse: Exploring the connection between health literacy and compliance in electroneuromyography procedures

Mustafa Hüseyin Temel — 2025-04-01

Objective: The aim of this study was to investigate a possible correlation between health literacy (HL), anxiety and compliance during electroneuromyography (ENMG) procedure.

Methods: This cross-sectional study was conducted at Başakşehir Çam and Sakura Hospital, including a total of 222 patients. After obtaining informed consent, the patients completed demographic and disease- related questionnaires as well as the Beck Anxiety Inventory (BAI) and Health Literacy Scale (HLS). Following the ENMG procedure, patients were then asked to complete the ENMG Compliance Questionnaire (ECQ) which was developed by the authors.

Results: A statistically significant weak negative association was found between the HLS and BAI scores and ENQ and BAI scores (p < 0.001, r = -0.24 and p<0.001, r= -0.259, respectively). Additionally, there was a statistically significant moderate positive correlation observed between the ECQ and HLS scores (p < 0.001, r = 0.408). A statistically significant difference was observed between the genders in terms of the BAI scores (p < 0.001). No statistically significant difference was found in the HLS and ECQ scores between genders. Analyses also revealed that individuals with no formal education exhibited significantly lower HLS scores than patients with higher education (p=0.001).

Conclusions: The results of this study indicated a notable link between the level of HL and increased compliance, as well as decreased anxiety, in individuals who undergo the ENMG procedure. Improving HL through targeted distribution of healthcare information via educational initiatives and ensuring broad availability of reliable health resources could potentially have a positive effect on patient compliance.

Comparing the effects of post-isometric relaxation and hold-relax technique for cervicogenic headache among computer users

Tejasri Balaji — 2025-04-01

Background & Objective: Cervicogenic headaches (CGH) can be caused by sedentary lifestyles and extended periods of time in fixed positions while using computers. Adapting to this sedentary lifestyle leads to neck and head pain, which is a prominent issue among adult computer users with a prevalence rate of 28%. Still, there is a lack of evidence on the effect of exercise and other physiotherapy treatments on cervical headaches. Therefore, the objective of this study was to compare the effects of Post-Isometric Relaxation (PIR) and the hold-relax technique on computer users suffering from CGH.

Method: Forty-eight patients were randomly assigned to the PIR (n = 24) and Hold-Relax (n = 24) groups in this experimental study. Both groups received conventional physiotherapy in common. The total duration of the exercise the participants exposed was 4 weeks. The pre-test was conducted prior to the intervention, and the post-test was carried out 4 weeks after the completion of the intervention. The pre- and post-intervention outcomes were measured using the pain Numerical Rating Scale, Headache Disability Index (HDI), Copenhagen Neck Functional Disability Scale, Cervical Flexion Rotation Test, and neck range of motion. The data were analyzed with SPSS.

Result: The CGH participants in the PIR and Hold-Relax groups had a significant improvement in the tested outcomes between their pre- and post-exercise values (p <0.0001). However, the hold-relax technique found to have a significant reduction in HDI (p < 0.01) than post-isometric relaxation.

Conclusion: Both post-isometric relaxation and the hold-relax technique were beneficial in CGH. However, as compared to PIR, the hold-relax technique was more effective.

Ictal and interictal optical coherence tomography angiography findings in patients with migraine

Yasemin Ekmekyapar Fırat — 2025-04-01

Background & Objective: Previous studies have suggested that changes in ocular vessels may occur because of vascular mechanisms involved in the pathogenesis of migraine. This study aimed to evaluate the vascular density in the radial peripapillary capillary (RPC) segment by optical coherence tomography angiography (OCTA) in ictal and interictal periods in patients with migraine.

Methods: In this study, the RPC vessel density was assessed by OCTA in the ictal and interictal periods in the same cohort consisting of 27 patients with migraine with and without aura. The ictal and interictal OCTA results were compared. Statistical analyses were done according to the sociodemographic and clinical data.

Results: No statistically significant differences were observed in vessel density in either the ictal or interictal periods in patients with migraine with and without aura.

Conclusion: Migraine may not have a direct impact on the RPC vessel density. However, the inconsistent results of OCTA in migraine cases may be due to the differences in the study designs in the literature. The protocols for OCTA use in migraine might help to homogenize study designs and improve data collection.

The effect of virtual reality in the treatment of migraine type headaches: A prospective, controlled, multicenter clinical study

Safa Dönmez — 2025-04-01

Background & Objective: Migraine is the third most common disease and the second leading cause of neurological disability globally. Alternative treatments are needed due to the limitations of conventional medications. Virtual reality (VR) shows promise in pain management. This study evaluates the efficacy of VR technology combined with classical music as an adjunctive treatment for acute migraine in an emergency department (ED).

Methods: In a prospective, non-randomized study, 140 patients with acute migraines at two urban EDs were divided into a control group receiving intravenous dexketoprofen and an intervention group receiving the same treatment plus VR exposure using Oculus Quest 2. Pain was measured with the Visual Analog Scale (VAS) at various intervals. Primary outcomes were changes in VAS scores and the need for rescue medication; secondary outcomes were side effects.

Results: Of the 140 patients, 131 completed the study. The VR group exhibited significantly greater reductions in VAS scores at all time points compared to the control group (p<0.001). The need for rescue medication was also significantly lower in the VR group (p<0.001). Kaplan-Meier analysis indicated a more rapid and sustained pain relief in the VR group.

Conclusion: The addition of VR technology to standard pharmacological treatment significantly enhances pain relief in acute migraine attacks and reduces the need for rescue medication. This suggests that VR could be a valuable adjunctive tool in the ED for managing acute migraine pain.

The role of curcumin supplementation in patients with migraine: A meta-analysis of randomized controlled trial

Xingke Zhu — 2025-04-01

Objectives: Migraine is a repeated, chronic and neurovascular disease that adversely affects the quality of life and increases the risk of cerebral lesion. According to some previous studies, curcumin, the orange-yellow substance of turmeric, may possess anti-headache property according to several studies. This study aimed to meta-analytically evluate the anti-headache effect of curcumin supplementation in patients with migraine.

Methods: Five databases were searched as of September 30, 2022 to identify all eligible randomized controlled trials. The random-effect Hunter-Schmidt model was used to calculate the effect sizes based on the heterogeneity. The PROSPERO registration number for this meta-analysis is CRD42023409829 (https://www.crd.york.ac.uk/PROSPERO/).

Results: Four studies involving 170 patients finally met our inclusion criteria. Curcumin supplementation showed a significant difference in the severity of migraine symptoms compared with placebo (Hedges’s g= -0.75, 95% confidence interval (CI) =-1.44 to -0.07, P= 0.03). The results of subgroup analyses indicated that curcumin significantly reduce the duration of migraine in patients over 35 years of age (Hedges’s g= -0.63, 95%CI= -1.07 to -0.19, P< 0.01) and high-dose curcumin significantly reduced the severity of migraine symptoms (Hedges’s g= -1.65, 95%CI= -2.32 to -0.97, P< 0.01).

Conclusions: Curcumin supplementation may relieve the severity of headache symptoms in migraine sufferers and appear to be more effective for reducing the headache duration in patients over 35 years of age.

A retrospective clinical trial of gabapentin combined with duloxetine for the treatment of neuropathic pain after maxillofacial fracture

jianhong zhou — 2025-04-01

Background & Objectives: Neuropathic pain (NPP) following a maxillofacial fracture can decrease patients’ quality of life and lead to numerous mental and psychological issues. However, using gabapentin alone for neuralgia only yields moderate results. Consequently, this study’s primary objective was to examine the effectiveness and safety of combining gabapentin and duloxetine to alleviate NPP subsequent to a maxillofacial fracture.

Methods: In this retrospective study, we examined patients diagnosed with NPP following maxillofacial fractures from January 2017 to December 2023 at our hospital. All patients received a combination of gabapentin and duloxetine for a 12-week period. We evaluated the effects of this combination on patients using the Visual Analog Scale (VAS), the Pittsburgh Sleep Quality Index (PSQI), the Self-Assessment Scale for Anxiety (SAS), the Hamilton Assessment of Depression (HAMD), and the 36-item Short-Form Survey (SF-36).

Results: This study included a total of 63 patients. After treatment combining gabapentin and duloxetine, there was a significant decrease in VAS, SAS, HAMD, and PSQI scores (P<0.001). There was also a significant improvement in life quality (P<0.05). Sleep staging results showed improved sleep quality post- treatment. Patients experienced longer total sleep time (P<0.001), fewer awakenings (P<0.05), and reduced awakening duration (P<0.05). Furthermore, stress duration six months post-treatment was significantly shortened (P<0.05).

Conclusions: This study indicated that the combined treatment of gabapentin and duloxetine was highly effective for post-maxillofacial fracture NPP. This combination notably improved patients’ pain levels, overall quality of life, sleep patterns, and levels of anxiety and depression.

Effectiveness of acceptance and commitment therapy for reducing emotional burden in family caregivers of patients with dementia: A pilot study

Jiyoung Gwak — 2025-04-01

Background & Objective: Recently, psychoeducational support to caregivers of patients with dementia (CPWD) has attract much interested. Acceptance and commitment therapy (ACT) which accept negative thought has been arising as a next generation of CBT. Here, we investigate the effect of ACT on emotional stress of caregivers of patients with dementia.

Method: The family caregivers of patients who have behavioral psychomotor symptom in dementia were recruited in this study. Thirteen participants in the intervention group and thirteen participants in the control group were analyzed. The participants in experimental group underwent a 6-week ACT program in one on one, face to face format. The outcome measurement were Beck anxiety inventory (BAI), Beck depression inventory-Ⅱ (BDI-Ⅱ), Zarit burden inventory (ZBI) and acceptance action questionnaire-16 (AAQ-16).

Results: In experimental group, the score of BAI, BDI-Ⅱ, ZBI and AAQ-16 significantly improved compared to baseline score. The difference of the change of the score of BAI, BDI-Ⅱ and ZBI after ACT program showed significant difference between intervention and control group. The change of BDI-Ⅱ significantly correlated with the changes of AAQ-16.

Conclusion: The result of this study showed that the depression, anxiety, and caregiver burden markedly reduced in intervention group compared to control group. The change of depression is correlated with the change of the degree of acceptance. Our results support that ACT can be useful counselling program for caring of family of CPWD.

Estrogen-related gene INPP5D is a potential biomarker for Alzheimer’s disease

Qiao-Qiao Wang — 2025-04-01

Objective: This study aims to leverage bioinformatics methodologies to screen genes related to Alzheimer’s disease (AD) and estrogen, unravel the interplay between estrogen and Alzheimer’s pathophysiology, and furnish a foundation for the clinical treatment of AD.

Methods: Through accessing AD transcriptomics data from the GEO database, we examined differentially expressed genes (DEGs) and elucidated their functional roles via GO and KEGG analyses. Also, we constructed a protein interaction network. Furthermore, we took the intersection between genes identified by the weighted gene co-expression network and estrogen-related DEGs, then obtained key genes through machine learning and verified them through internal data sets. Finally, immune infiltration analysis was performed on the data of patients with AD.

Results: 326 DEGs were obtained from GSE118553, predominantly enriched in nucleotide diphosphorylation (biological process), nucleotide excision repair complexes (cellular composition), neurotrophic factor binding (molecular functions), and sugar metabolism (signaling pathway). Through weighted gene co-expression network analysis and the intersection of DEGs, three estrogen-related genes were screened out: INPP5D, ENO1, and NOP16. Next, INPP5D was selected as the pivotal gene by the random forest tree algorithm. The prediction model was built on INPP5D, and the AUC of the ROC curve equals 0.876. After single-sample gene enrichment analysis, the samples clustered into high- and low-immune groups. Intriguingly, there was a positive correlation between these two groups on activated NK cells and M1 macrophages, and a negative correlation between M1 macrophages and T cells CD4 memory resting.

Conclusion: The estrogen-related gene INPP5D is a potential biomarker for AD, which provides a new perspective and scientific basis for the development of AD treatment strategies based on hormone replacement therapy.

Clinical features of antibody-negative autoimmune encephalitis: A meta-analysis and literature review

Weiwei Gao — 2025-04-01

Objective: This study aimed to conduct a comprehensive literature review and meta-analysis of antibody-negative Autoimmune encephalitis (AE) and to quantitatively compare the clinical features of antibody-negative versus antibody-positive AE patients.

Methods: Systematic searches of the PubMed, Embase, Web of Science, and Chinese databases (China National Knowledge Infrastructure, Wanfang, and VIP) were conducted up to December 2023. Relevant articles including references and similar documents from retrieved papers, were further screened. Standardized mean differences (SMD) or odds ratios (OR) with 95% confidence intervals (CI) were calculated using fixed-effect or random-effect models for demographic characteristics, clinical manifestations, magnetic resonance imaging (MRI) and electroencephalogram (EEG) abnormalities, and cerebrospinal fluid (CSF) parameters. Subgroup analyses were performed to identify sources of heterogeneity.

Results: Six studies (one prospective and five retrospective case-control studies) detailing the clinical features of antibody-negative AE were included in the meta-analysis. Compared to patients with antibody-positive AE, those with antibody- negative AE had a significantly older age at onset (SMD = 0.26, 95% CI: 0.04, 0.49; P = 0.02), a lower incidence of concurrent tumors (OR = 0.57, 95% CI: 0.31, 1.07; P = 0.08), and a lower CSF pleocytosis rate (OR = 0.46, 95% CI: 0.27, 0.79; P = 0.01). No significant differences were observed in sex distribution, clinical manifestations, MRI or EEG abnormality rates, or CSF protein concentrations. Furthermore, subgroup analysis demonstrated a lower prevalence of epileptic seizures among Western populations with antibody-negative AE compared to their Asian counterparts (P = 0.03).

Conclusion: This meta-analysis revealed significant differences in age of onset, tumor comorbidity, and CSF pleocytosis rate between patients with antibody-negative and antibody-positive AE, contributing to a more nuanced understanding of antibody-negative AE among clinicians.

Investigation of exercise barriers-benefits, kinesiophobia, physical activity, fatigue and depression in individuals with multiple sclerosis

Fatih Özden — 2025-04-01

Background & Objective: Despite the benefits of exercise for individuals with multiple sclerosis (MS), physical activity levels in people with MS (pwMS) remain lower than in healthy controls. Identifying barriers to exercise and related factors is crucial for promoting physical activity in pwMS. This study aimed to examine perceived exercise barriers and benefits, along with fatigue, kinesiophobia, physical activity levels, and depressive symptoms in pwMS.

Methods: This cross-sectional study included 104 participants (60 pwMS, 44 healthy controls). The Exercise Benefits and Barriers Scale (EBBS) assessed perceived exercise barriers and benefits. Kinesiophobia, physical activity, fatigue, and depression were evaluated using the “Tampa Scale for Kinesiophobia and Fatigue (TSK-F), the International Physical Activity Questionnaire-Short Form (IPAQ-SF), the “Fatigue Severity Scale (FSS), and the “Depression, Anxiety, and Stress Scale (DASS-21).

Results: EBBS scores were significantly higher in pwMS than in healthy controls (p<0.001). The pwMS group also showed higher TSK-F, FSS, and DASS-21 scores (p<0.001) and lower IPAQ-SF scores (p<0.001). EBBS scores correlated significantly with TSK-F (r=0.306) and IPAQ-SF (r=-0.328, p<0.05). A positive correlation was found between EBBS-barriers and TSK-F (r=0.358, p<0.001), while EBBS-benefits correlated with TSK-F and IPAQ-SF (r=0.281, r=-0.307, p<0.05).

Conclusion: PwMS had lower awareness of exercise benefits and perceived greater barriers. Higher kinesiophobia, fatigue, and depression were evident, along with lower physical activity levels. A stronger perception of exercise barriers was associated with greater kinesiophobia and lower physical activity in pwMS. Enhancing exercise awareness and reducing barriers may improve physical activity, fatigue, and mental health in pwMS, guiding future interventions.

Real-world experience of ocrelizumab in patients with multiple sclerosis: A single-center study

Emine Rabia Koc — 2025-04-01

Objective: We aimed in this study to obtain real-world data in MS patients treated with ocrelizumab at our center and examine the drug’s efficacy, safety, and side effects.

Methods: We conducted a retrospective study and included MS patients receiving at least one infusion therapy of ocrelizumab at our center. Demographic information, clinical and radiological course of the patients, whether they were infected with the COVID-19 virus, vaccination status, and drug-related safety data were collected and analyzed.

Results: Two hundred and forty patients meeting the inclusion criteria were included. Before ocrelizumab treatment, the mean annualized relapse rate (ARR) was 0.816 (CI:0.66-0.99) in the RRMS group fell to 0.10 (CI: 0.06- 0.16) after the ocrelizumab initiation(p<0.001). Similarly, ARR fell from 0.44 (CI:0.28-0.67) to 0.04 (CI:0.001-0.13) in the SPMS group after treatment initiation (p<0.001). The most common reason for the treatment change with ocrelizumab was increased disease activity (n:101, measured either clinically, radiological, or both ), disease progression (n:60), or the adverse effects (n: 23 ) of previous DMT. Infection was seen in 80 of 240 patients. The most frequent condition was COVID-19 infection (n=45) related to a pandemic, followed by urinary tract infection (n=18) and upper respiratory tract infection (n=14). While the cancer screening results of 1 patient were within normal limits at the beginning, breast cancer was detected six months after starting ocrelizumab.

Conclusions: Our real-world data with ocrelizumab have shown that it is an effective and well-tolerated disease-modifying therapy supporting the results of pivotal studies.

Challenges faced by pediatric patients with multiple sclerosis during disease progression and treatment: A multicenter cross-sectional study in Türkiye

Didem Yüksel — 2025-04-01

Background & Objective: Multiple sclerosis is a chronic and progressive disease characterized by inflammation, demyelination and degeneration of the central nervous system. This study aimed to describe the sociodemographic and clinical characteristics of children with multiple sclerosis.

Methods: The cross-sectional study was collected data from 120 children who met the research criteria and were under follow-up at 7 hospitals in Türkiye between August 2021 and February 2022. Ethical approval was obtained from the Medical Research Ethics Committee of Ege University. The researchers developed the “The Sociodemographic Form “used in the study by based on a comprehensive literature review and previous research experiences. The form was used according to expert opinion.

Results: The study included 120 eligible patients, of whom 71.2% were girls. The mean age (±SD) at disease onset was 13.6±2.2 years, while the mean age at the time of the study was 15.7±1.5 years. Most of the participants were high school students (84.2%), and 53.3% resided in metropolitan areas. All participants were receiving disease-modifying therapy. The study found that 67.5% of the children had school absenteeism due to the disease. Furthermore, 75% of the children experienced supratentorial symptoms, with 50% presented with optic symptoms, and 37.5% exhibiting brainstem symptoms prior to diagnosis. Drug-related side effects were reported in 58.3% of children. Additionally,99.2% of the children received information about the disease. Furthermore, 75% of the children experienced challenges during the disease and treatment process. Among these children who encountered difficulties, 52.5% reported psychological problems, 42.5% experienced side effects due to medication, 42.5% had difficulty accessing accurate and sufficient information about disease and treatment management, 32.5% encountered social and school-related issues, and 5.8% had concerns related to the clinical environment.

Conclusion: Childhood multiple sclerosis is more prevalent among girls, particularly in the relapsing- remitting form. The most commonly used treatments for pediatric multiple sclerosis include interferon beta-1a and glatiramer acetate. The findings of this study indicate that a significant proportion of participating children encountered challenges during the disease and treatment process, with more than half experiencing drug-related side effects. These challenges underscore the potential negative impact on treatment adherence in this population.

Analysis of clinical features and literature review of myelin oligodendrocyte glycoprotein antibody-associated disease

Bo Liu — 2025-04-01

Objective: The purpose of this study is to analyze the clinical features of myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD).

Methods: A retrospective analysis was conducted on eight patients diagnosed with MOGAD at Anyang City People’s Hospital, Henan, China.

Results: Among the eight patients, five were male and three were female, with an age range of 31 to 68 years and a median age of 46.88 years. Both serum and/or cerebrospinal fluid were tested positive for the MOG antibody. Optic neuritis, myelitis, and cortical encephalitis were among the clinical manifestations. A history of viral infection prior to the onset of the disease (3/8) was observed, and one case also tested positive for the AQP-4 antibody.

Conclusion: Optic neuritis and myelitis are the primary clinical manifestations of MOGAD, while a small percentage of patients also exhibit cerebral encephalitis. Testing for the MOG antibody holds diagnostic significance as the condition is easily misdiagnosed.

Xueshuantong improves therapeutic outcome and quality of life of elderly patients with benign paroxysmal positional vertigo after Epley maneuver

Xiaojiang Zhang — 2025-04-01

Objective: Benign paroxysmal positional vertigo (BPPV) is a common peripheral vestibular disorder. This study aimed to evaluate the therapeutic effect of Xueshuantong in patients with BPPV treated with the Epley maneuver.

Methods: In this randomized study, 97 patients diagnosed with posterior canal BPPV who met the inclusion and exclusion criteria were allocated to the control group (Epley maneuver) and the experimental group (Epley maneuver plus Xueshuantong). All patients were assessed using the vertigo symptom scale (VSS), Berg balance scale (BBS), dizziness handicap inventory (DHI), and visual analog scale (VAS) before treatment and again on day 14 after treatment. Recurrence rates were assessed during 6-month follow-up period.

Results: Compared with the control group, the therapeutic outcomes of BPPV were significantly improved in the experimental groups. Significant decrease in VSS (20.8 vs 33.1), total DHI (35.1 vs 46.9), sub DHI and VAS (2.2 vs 7.4) scores and significant increase in BBS scores (55.5 vs 31.8) were observed following Xueshuantong treatment. Xueshuantong treatment also resulted in significantly reduced recurrence rates (81.6% vs. 91.7%; RRR = 11%), with no additional adverse effects.

Conclusions: Post-Epley maneuver treatment with Xueshuantong improves the therapeutic outcomes, reduces the residual dizziness and increases quality of life of elderly patients with BPPV treated with the Epley maneuver.

The warning criterion of intraoperative bulbocavernosus reflex monitoring in adult patients with lumbosacral intraspinal tumor

Tuanfeng Yang — 2025-04-01

Objective: There are currently no standard warning criteria for intraoperative neurophysiological monitoring (IONM) of bulbocavernosus reflex (BCR). This study aimed to preliminary detect a practical warning criterion for use in intraoperative BCR monitoring in adult patients with lumbosacral intraspinal tumor.

Methods: Adult patients with lumbosacral intraspinal tumor who underwent surgery with BCR monitoring were recruited. Patients were classified into four groups according to the amplitude decline rate of BCR responses at the end of surgery compared with the baseline: Group 1, <50%; Group 2, >50% and <75%; Group 3, >75% and <100%; Group 4, 100% (BCR disappeared). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for three specified cutoff values of BCR amplitude decline rate at 50%, 75% and 100% to predict postoperative voiding function were calculated. Receiver operating characteristic curve analysis was used to determine the optimal cutoff value of BCR amplitude decline. Voiding function was evaluated based on subjective urinary symptoms and postvoid residual urine volume measurement at 1 month post-operatively.

Results: A total of 57 patients were included in the study. There were 33 (57.9%) males and the mean age was (51.2±15.3) years. There were 46 patients (26 males) in Group 1, 3 patients (2 males) in Group 2, 3 patients (1 male) in Group 3, and 5 patients (4 males) in Group 4. Two patients (2 males) in Group 1, 1 patient (0 male) in Group 2, 2 patients (0 male) in Group 3, and 4 patients (4 males) in Group 4 demonstrated worsened voiding function at 1 month post-operatively. When the warning criterion of BCR amplitude decline rate was set as 50%, the sensitivity, specificity, PPV, and NPV of BCR monitoring for worsened voiding were 77.8%, 91.7%, 63.6%, and 95.7% respectively. When the warning criterion was 75%, the sensitivity, specificity, PPV, and NPV were 66.7%, 95.8%, 75.0%, and 93.9% respectively. When the warning criterion was 100%, the sensitivity, specificity, PPV, and NPV were 44.4%, 97.9%, 80.0%, and 90.4% respectively. According to the ROC curve analysis, the optimal cutoff value of BCR amplitude decline for predicting voiding function at 1 month post-operatively was 66.5%. The area under curve, sensitivity, and specificity were 0.813, 77.8% and 95.8% respectively.

Conclusions: Intraoperative BCR monitoring is a valuable tool to be performed during surgery in adult patients with lumbosacral intraspinal tumor. The cutoff value of BCR amplitude decline rate at 100% (all or none criterion) can be used to predict postoperative voiding function, and the absence of BCR is a robust indication for poor voiding post-operatively. As a warning criterion, the cutoff value of BCR amplitude decline at 66.5% may be practical.

Neuroimaging utilization and clinical indications in geriatric patients presenting to the emergency department with dizziness

Handan Özen Olcay — 2025-04-01

Background & Objective: With the increasing prevalence of advanced technology, there has been a notable rise in the use of neuroimaging for patients presenting to the emergency department (ED) with dizziness in recent years. This study aims to investigate the frequency of neuroimaging, the clinical indications for its use, the findings, and the factors influencing these findings in geriatric patients presenting with dizziness to the ED.

Methods: The study included patients aged 65 and older who presented to the ED with dizziness between January 1, 2018, and December 31, 2023, and who had undergone brain computed tomography (CT) and/or diffusion-weighted magnetic resonance imaging (DW-MRI), with complete data available. Intracranial masses, acute-subacute ischemic findings, intraparenchymal and subarachnoid hemorrhage, and brain edema detected on brain CT were classified as significant pathologies. Additionally, patients were compared based on the presence of ischemia on DW-MRI with other variables.

Results: The study included 508 patients who underwent CT scan and/ or DW-MRI. Significant pathology was detected in 6.3% of those who underwent CT scan. Among the patients who underwent DW-MRI, 9.1% were found to have acute-subacute ischemia. The incidence of significant pathology and ischemia was statistically higher in patients who underwent CT scan and DW-MRI due to indications such as aphasia, focal neurological deficits, vertical nystagmus, ataxia, and dysmetria/dysdiadochokinesia (p<0.05).

Conclusion: In geriatric patients, emergency neuroimaging should be performed considering clinical characteristics and risk factors. Limiting the use of CT scan to specific indications rather than routine use, and prioritizing DW-MRI in cases where ischemic events are suspected, may be more appropriate.

Provision of health services for children with learning difficulties: A retrospective study at a tertiary centre in Malaysia

Wee Vien Khoo — 2025-04-01

Background & Objective: Learning difficulties pose significant challenges for academic achievement and skill development in children. This study explored characteristics of children with learning difficulties and assessed existing practices at a tertiary medical centre in Malaysia.

Methods: A retrospective study was conducted at the Universiti Malaya Medical Centre, including children aged 6 to 18 with learning difficulties. Data was obtained from electronic medical records, and 187 cases were analysed for demographic details, referral patterns, diagnoses and associated conditions.

Results: The study revealed that learning difficulties often emerged by age 5, and primarily affected males, characterised by behavioural concerns. Half of the children were in mainstream education without additional support. Challenges in the assessment process were due to limited healthcare professionals, and absence of standardised, linguistically and culturally applicable tools. Associated conditions, including developmental delays, language disorders, and attention-deficit hyperactivity disorder were commonly found.

Conclusion: The study identified service gaps in the healthcare setting vital for planning future services, necessitating increased resources and funding for child development centres nationwide. Such challenges necessitate the shift from diagnosis-focused approaches, to identifying accommodations for learning within existing structures. Future research should prioritise reliability and validity of locally-developed assessment tools to enhance the assessment process. Larger-scale audits are crucial for accurate insights into current practices of assessing learning difficulties in Malaysia.

Clinical and genetic findings in an Iraqi family with TMEM67-associated Joubert syndrome

Sahar Kareem Al-Mozani — 2025-04-01

Joubert syndrome is a rare, genetically complex disorder that significantly affects brain development, characterized by hallmark features such as hypotonia, developmental and motor delays, and the distinctive molar tooth sign on brain MRI. The disorder frequently arises from mutations in genes essential for ciliary function, crucial for cellular signaling and development across multiple organ systems. TMEM67, one of these genes, is particularly associated with cases involving multi-organ dysfunction, including kidney and liver abnormalities. We report a novel homozygous mutation in TMEM67 (c.797A>T; p.Asp266Val) in a 7-year-old male from a consanguineous Iraqi family, who presented with classic neurological symptoms of Joubert syndrome and mild hepatic dysfunction. The mutation, located in exon 8 (NM_153704.6), substitutes aspartic acid with valine, likely disrupting protein structural integrity and function through the loss of polar charge. Using exome and Sanger sequencing, we confirmed this pathogenic variant, emphasizing the necessity of comprehensive genetic analysis for accurate diagnosis and management, especially in populations with high consanguinity rates. Our findings expand the mutational spectrum of TMEM67 and highlight potential mutation hotspots related to severe multi-organ involvement. This study enriches the TMEM67 variant database and stresses the importance of genetic counseling for guiding patient care and reproductive decisions.

How common are unruptured intracranial aneurysms misdiagnosed as a serious ocular disease? – An illustrative case

Cheau Wei Chin — 2025-04-01

Unruptured intracranial aneurysm rarely present with visual dysfunction and could be misdiagnosed as serious ocular disease when there is associated vision abnormality. Anterior communicating artery (ACOM) aneurysm is a rare cause of non-glaucomatous optic neuropathy and could cause anterior visual pathway compression due to its proximity to optic nerve.1 We hereby present a case of co- existing ACOM aneurysm and meningioma with unilateral fully cupped disc mimicking glaucomatous optic neuropathy, with literature review of intracranial aneurysms that had been misdiagnosed as ocular pathology.

Unilateral variant of nasogastric tube syndrome in a patient with stroke: A case report

Sung-il Hwang — 2025-04-01

Nasogastric tube (NGT) is often used in the early stages of stroke for nutritional support. Nasogastric tube syndrome (NGTS) is a rare but a life-threatening disorder characterized by the triad of NGT insertion, throat pain and vocal cord palsy. A 67-year-old man was admitted for right basal ganglia and intraventricular hemorrhage. He had a history of diabetes mellitus and hypertension. After stereotactic cranial aspiration, NGT feeding was started. At 11 weeks after NGT intubation, he presented with an ambiguous sore throat and stridor. Right posterior cricoarytenoid inflammation and ipsilateral vocal cord palsy was identified through neck computed tomography (CT). Removal of the NGT, endotracheal intubation and intravenous ceftriaxone administration were performed. His symptoms resolved completely and did not recur until discharge. NGTS should be evaluated early in stroke patients with NGTs who present with sore throat and stridor. Increased awareness and early diagnosis of NGTS are important for appropriate management and prevention of progression to fatal clinical outcome.

Intractable hiccups as a sole manifestation of medullary cavernous hemangioma

Sung-Hyun Lee — 2025-04-01

Intractable hiccups lasting over 48 hours can indicate serious medical conditions, including neurological disorders. Typically, such disorders present with other neurological symptoms, but hiccups may, in some cases, occur as the sole manifestation, delaying the underlying diagnosis. We report the case of a 37-year-old previously healthy man who experienced intractable hiccups for more than 50 days. Initial investigations, including chest and abdominal imaging and endoscopy, were unremarkable except for gastroesophageal reflux disease (GERD), which did not improve with standard treatment. A neurological examination revealed no abnormalities, but brain MRI showed a small cavernous hemangioma with subacute hemorrhage near the solitary nucleus in the medulla, which was thought to be responsible for the intractable hiccups. This case highlights the importance of considering small medullary lesions in the differential diagnosis of persistent hiccups, even in the absence of other neurological symptoms, and underscores the role of the solitary nucleus in the pathophysiology of intractable hiccups.

A case report of SEPN1-related myopathy: Expanding the spectrum of clinical, genetic and radiological features

Ahmed Bamaga — 2025-04-01

SEPN1-related myopathies (SEPN1-RM) encompass a rare subset of neuromuscular disorders stemming from mutations in the SELENON gene. Here, we present a case of a 15-year-old Saudi child harboring an autosomal recessive homozygous c.2T>A. (chr1:25800232 T>A) (NM_020451.3), exhibiting a distinct clinical profile of hypotonia, motor delay, muscle weakness, scoliosis, and sleep apnea. Advanced genetic testing revealed additional heterozygous variants in the CNGA1 and BTD genes. Our report underscores the complexity of SEPN1-RM, highlighting the challenges in correlating genotypes with phenotypes and emphasizing the early onset of respiratory insufficiency in affected individuals. This case contributes novel insights to the clinical and genetic landscape of SEPN1-RM, emphasizing the need for continued research to enhance diagnostic and therapeutic strategies for improved patient care and outcomes.

Rare trigeminovascular signs during migraine attack

Aslihan TASKIRAN-SAG — 2025-04-01

Severe headache and physical findings in the face and neck area may imply serious intracranial pathology and warrant further investigations including laboratory tests and imaging. We present two migraine cases with unusual trigeminovascular cutaneous findings (i.e., periorbital bruising and facial swelling). Recognition of these rare manifestations of migraine may help the clinician in differential diagnosis and prevent unnecessary investigations. A pathophysiological discussion of these signs is provided.

Neuropsychiatric lupus with cerebral cortical lamellar necrosis: A case report

Kang Wang — 2025-04-01

Systemic lupus erythematosus (SLE) is an autoimmune disease, and when it presents with neurological complications, it is termed neuropsychiatric systemic lupus erythematosus (NPSLE). Cortical laminar necrosis (CLN) refers to the necrosis of neurons in one or more layers of the cerebral cortex. This report presents a case of NPSLE with CLN in a 43-year-old female patient, diagnosis was based on clinical manifestations and MRI. The pathogenesis of CLN is complex, and its clinical presentations are varied. Thus, future research should focus on enhancing the understanding of this disease to improve its diagnosis and treatment.